Certificate of Child Health Examination

Student’s Name

Last First Middle

Birth Date

(Mo/Day/Yr)

Sex

Race/Ethnicity

School/Grade Level/ID#

Street Address City ZIP Code

Parent/Guardian

Telephone (home/work)

HEALTH HISTORY: MUST BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER

ALLERGIES

(Food, drug, insect, other)

Yes

List:

MEDICATION

(Prescribed or taken on a

regular basis)

Yes

List:

Diagnosis of Asthma?

Yes No

Child wakes during night coughing?

Yes No

Birth Defects?

Yes No

Developmental delay?

Yes No

Blood disorder? Hemophilia, Sickle Cell, Other? Explain.

Yes No

Diabetes?

Yes No

Head injury/Concussion/Passed out?

Yes No

Seizures? What are they like?

Yes No

Heart problem/Shortness of breath?

Yes No

Heart murmur/High blood pressure?

Yes No

Dizziness or chest pain with exercise?

Yes No

Eye/Vision problems?

Glasses Contacts

Last exam by eye doctor

Other concerns? (Crossed eye, drooping lids, squinting, difficulty reading)

Ear/Hearing problems?

Yes No

Bone/Joint problem/injury/scoliosis?

Yes No

Loss of function of one of paired

organs? (eye/ear/kidney/testicle)

Yes No

Hospitalization?

When? What for?

Yes No

Surgery? (List all)

When? What for?

Yes No

Serious injury or illness? Yes No

TB skin test positive (past/present)? Yes* No

*If yes, refer to local

health department

TB disease (past or present)? Yes* No

Tobacco use (type, frequency)? Yes No

Alcohol/Drug use? Yes No

Family history of sudden death before

age 50? (Cause?)

Yes No

Additional Information:

Information may be shared with appropriate personnel for health and educational purposes.

Parent/Guardian

Signatures:

Date:

IMMUNIZATIONS: To be completed by health care provider. The mo/day/yr for every dose administered is required. If a specific vaccine is medically

contraindicated, a separate written statement must be attached by the health care provider responsible for completing the health examination

explaining the medical reason for the contraindication.

REQUIRED

Vaccine/Dose

DOSE 1

MO DA YR

DOSE 2

MO DA YR

DOSE 3

MO DA YR

DOSE 4

MO DA YR

DOSE 5

MO DA YR

DOSE 6

MO DA YR

DTP or DTaP

Tdap; Td or Pediatric DT

(Check specific type)

Tdap Td DT

Tdap Td DT Tdap Td DT Tdap Td DT Tdap Td DT Tdap Td DT

Polio (Check specific type)

IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV

Hib Haemophiles Influenza

Type B

Pneumococcal Conjugate

Hepatitis B

MMR Measles, Mumps,

Rubella

Varicella (Chickenpox)

Meningococcal Conjugate

RECOMMENDED, BUT NOT REQUIRED Vaccine/Dose

Hepatitis A

HPV

Influenza

Other: Specify Immunization

Administered/Dates

Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below.

If adding dates to the above immunization history section, put your initials by date(s) and sign here.

Signature

Title Date

Printed by Authority of the State of Illinois (COMPLETE BOTH SIDES) 12/23 IOCI 24-947

Comments: * indicates invalid dose

Dental Braces Bridge Plate Other

Student’s Name

Last First Middle

Birth Date

(Mo/Day/Yr)

Sex School

Grade Level/ID#

Certificates of Religious Exemption to Immunizations or Physician Medical Statement of Medical Contraindication

are reviewed and Maintained by the School Authority.

ALTERNATIVE PROOF OF IMMUNITY

1. Clinical diagnosis (measles, mumps, hepatitis B) is allowed when verified by physician and supported with lab confirmation. Attach copy of lab result.

*MEASLES (Rubeola) (MO/DA/YR) **MUMPS (MO/DA/YR) HEPATITIS B (MO/DA/YR) VARICELLA (MO/DA/YR)

2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official. Person signing below

verifies that the parent/guardian’s description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease.

Date of Disease Signature Title

3. Laboratory Evidence of Immunity (check one)

Measles* Mumps** Rubella Varicella

Attach copy of lab result.

*All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.

**All mumps cases diagnosed on or after July 1, 2013, must be confirmed by laboratory evidence.

Physician Statements of Immunity MUST be submitted to IDPH for review.

Completion of Alternatives 1 or 3 MUST be accompanied by Labs & Physician Signature:

PHYSICAL EXAMINATION REQUIREMENTS Entire section below to be completed by MD/DO/APN/PA

HEAD CIRCUMFERENCE if < 2-3 years old

HEIGHT WEIGHT BMI BMI PERCENTILE B/P

DIABETES SCREENING: (NOT REQUIRED FOR DAY CARE) BMI>85% age/sex Yes No And any two of the following: Family History Yes No

Ethnic Minority

Yes No Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) Yes No At Risk Yes No

LEAD RISK QUESTIONNAIRE:

Required for children aged 6 months through 6 years enrolled in licensed or public-school operated day care, preschool, nursery school and/or kindergarten.

(Blood test required if resides in Chicago or high-risk zip code.)

Questionnaire Administered?

Yes No

Blood Test Indicated?

Yes No

Blood Test Date Result

TB SKIN OR BLOOD TEST: Recommended only for children in high-risk groups including children immunosuppressed due to HIV infection or other conditions, frequent travel to or born in high

prevalence countries or those exposed to adults in high-risk categories. See CDC guidelines.

http://www.cdc.gov/tb/publications/factsheets/testing/TB_testing.htm.

No test needed Test performed Skin Test:

Date Read

Result:

Positive Negative

Blood Test:

Date Reported

NegativePositiveResult:

Value

LAB TESTS (Recommended) Date Results SCREENINGS Date Results

Hemoglobin or Hematocrit Developmental Screening

N/ACompleted

Urinalysis Social and Emotional Screening

Completed N/A

Sickle Cell (when indicated Other:

SYSTEM REVIEW Normal Comments/Follow-up/Needs Normal Comments/Follow-up/Needs

Skin Endocrine

Ears

Screening Result:

Gastrointestinal

Eyes

Screening Result:

Genito-Urinary

LMP:

Nose Neurological

Throat Musculoskeletal

Mouth/Dental Spinal Exam

Cardiovascular/HTN Nutritional Status

Respiratory

Diagnosis of Asthma

Mental Health

Currently Prescribed Asthma Medication:

Quick-relief medication (e.g., Short Acting Beta Agonist)

Controller medication (e.g., inhaled corticosteroid)

Other

NEEDS/MODIFICATIONS required in the school setting

DIETARY Needs/Restrictions

SPECIAL INSTRUCTIONS/DEVICES (e.g., safety glasses, glass eye, chest protector for arrhythmia, pacemaker, prosthetic device, dental bridge, false teeth, athletic support/cup)

MENTAL HEALTH/OTHER Is there anything else the school should know about this student?

If you would like to discuss this student’s health with school or school health personnel, check title:

Nurse Teacher Counselor Principal

EMERGENCY ACTION needed while at school due to child’s health condition (e.g., seizures, asthma, insect sting, food, peanut allergy, bleeding problem, diabetes, heart problem)?

NoYes

If yes, please describe:

On the basis of the examination on this day, I approve this child’s participation in (If No or Modified please attach explanation.)

PHYSICAL EDUCATION

NoYes Modified

INTERSCHOLASTIC SPORTS

NoYes Modified

MD DO APN PA

Signature DatePrint Name

Address Phone